- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.65 / $131.65 / $131.65
| Professional | | $131.65 | $131.65 | $131.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.00 / $292.00 / $438.00
| Professional | | $243.00 | $292.00 | $438.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.98 / $218.04 / $312.18
| Professional | | $178.98 | $218.04 | $312.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.76 / $331.18 / $525.36
| Professional | | $200.76 | $331.18 | $525.36 |